Healthcare Provider Details

I. General information

NPI: 1609260298
Provider Name (Legal Business Name): MARY KUTTLER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2015
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 HOSPITAL DR SUITE 200
GLEN BURNIE MD
21061-6904
US

IV. Provider business mailing address

203 HOSPITAL DR SUITE 200
GLEN BURNIE MD
21061-6904
US

V. Phone/Fax

Practice location:
  • Phone: 410-760-8840
  • Fax: 410-760-8847
Mailing address:
  • Phone: 410-760-8840
  • Fax: 410-760-8847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD01277
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: